Basic Information
| Provider Information | |||||||||
| NPI: | 1154556678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOGATCH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114393 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9601 BAPTIST HEALTH DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012173533 | ||||||||
| FaxNumber: | 5012173578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2009 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | A129673 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0005X | E12668 | AR | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 237276001 | 05 | AR | MEDICAID |